Form In-111 - Vermont Income Tax Return - 2016 Page 2
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1
2*161111200*
Keep a copy for
Taxpayer’s Last Name
Social Security Number
your records.
* 1 6 1 1 1 1 2 0 0 *
Enter amount from Line 22 ______________________________
5
.0 0
.0 0
.0 0
+
=
23. _____________________________________
24. _____________________________________
25. _____________________________________
Credit for Income Tax Paid to other
Vermont Tax Credits (Schedule IN-112,
Total Vermont Credits
State or Canadian Province
Part IV, Line 5 OR Schedule IN-119)
(Add Lines 23 and 24)
(Schedule IN-117, Line 21)
.0 0
26.
Vermont Income Tax after Credits (Subtract Line 25 from Line 22 . If Line 25 is more than Line 22, enter -0- . ) . . . . . . . 26. _______________________________________
.0 0
27. Use Tax (See instructions and chart) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27. _____________________________________
Check here to certify that no Use Tax is due
c
.0 0
28. Total Vermont Taxes (Add Lines 26 and 27) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28. _____________________________________
6
P
Children’s Trust Fund
Vermont Veterans Fund
Green Up Vermont
Nongame Wildlife Fund
.0 0
.0 0
.0 0
.0 0
.0 0
+
+
+
=
29a. _______________
29b. _______________
29c. _______________
29d. _______________
29e. _______________
.0 0
30. Total of Vermont Taxes and Voluntary Contributions (Add Lines 28 and 29e) . . . . . . . . . . . . . . . . . . . . . . . . . . 30. _____________________________________
7
.0 0
31a. From W-2, 1099, etc . Vermont Tax Withheld . . . . . . . . . . . . .31a.__________________________________
31b. From Vermont Form IN-114 Estimated Tax for 2016
.0 0
and/or Form IN-151, Extension with payment . . . . . . . . . . . . 31b.__________________________________
.0 0
31c. Earned Income Tax Credit (Schedule IN-112, Part III) . . . . .31c.__________________________________
.0 0
31d. Renter Rebate (Form PR-141, Line 9) . . . . . . . . . . . . . . . . . . 31d.__________________________________
31e. From Vermont Form RW-171 Vermont Real Estate
.0 0
Withholding (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .31e.__________________________________
31f. From Vermont Form WH-435 Estimated Income Tax
Payment made by Business Entity for Nonresident
.0 0
Partner, Member, or Shareholder . . . . . . . . . . . . . . . . . . . . . . 31f.__________________________________
31g. Low Income Child & Dependent Care Credit
.0 0
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31g.__________________________________
.0 0
31h. Total Payments and Credits (Add Lines 31a through 31g) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31h. _____________________________________
8
.0 0
32. Overpayment If Line 30 is less than Line 31h, subtract Line 30 from Line 31h . . . . . . . . . . . . . . . . . . . . . . . . . . . 32. _____________________________________
33a. Refund to be Credited to 2017 Estimated Tax Payment
.0 0
Amount on 31d cannot be credited to 2017 estimated tax payment . . . . . . . 33a. _________________________________
.0 0
33b. Refund to be Credited to 2017 Property Tax Bill . . . . . . . . . . . . . . . 33b. _________________________________
.0 0
REFUND AMOUNT
34.
(Subtract Lines 33a and 33b from Line 32) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34. _____________________________________
9
.0 0
35. If Line 30 is more than Line 31h, subtract Line 31h from Line 30 . See instructions on tax due . . . . . . . . . . . . . . . . 35. _____________________________________
AMOUNT DUE
37.
Interest and Penalty on Underpayment of
.0 0
.0 0
36. _______________________
Add Lines 35 and 36 . . . . 37. ______________________________________
Estimated Tax (Worksheet IN-152 or IN-152A)
For amended
returns only
Original refund received ___________
Refund due now _______________
Original payment _____________
Amount due now ____________
10
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
and belief, they are true, correct and complete . Preparers cannot use return information for purposes other than preparing returns .
Signature
Date
Occupation
Date of Birth (MM DD YYYY) Telephone Number
Signature. If a joint return, BOTH must sign.
Date
Occupation
Date of Birth (MM DD YYYY) Telephone Number
Check here if authorizing the Vermont Department of Taxes to discuss this return and attachments with your preparer.
Preparer’s signature
Date
Preparer’s
SSN or
Preparer’s
PTIN
Use Only
Firm’s name (or yours if self-employed) and address
EIN
Preparer’s Telephone Number
5454
To claim refund, mail to:
With payment, mail to:
Form IN-111, page 2 of 2
VT Department of Taxes, PO Box 1881, Montpelier, VT 05601-1881
VT Department of Taxes, PO Box 1779, Montpelier, VT 05601-1779
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